An "embedded culture of fear" in the mental health and addiction services department at the Bay of Plenty DHB created a "significant" level of clinical risk to patients.
That is according to a report by an independent consultant hired to look into the embattled department, where more than 70 staff members resigned in the preceding four years, and where people were found to be feeling "undervalued, unfairly treated, bullied and harassed".
The report led to a major leadership restructure at the department but the DHB refused to release the 20-page document to the Bay of Plenty Times under the Official Information Act last year, instead handing over a powerpoint slide summary given to staff.
In fact, staff were not even shown the report until a few weeks ago, when the DHB released a heavily redacted version on the advice of the Chief Ombudsman following a complaint by the Bay of Plenty Times.
The Ministry of Health, after being informed of the report, moved quickly to meet with DHB leadership about the issues.
This month, Health Minister Dr David Clark said he became aware of the problems soon after the Government was formed in the 2017 election.
"Clearly, the situation was unacceptable".
The report, by Wellington-based consultant Craig O'Connell, was commissioned shortly after the Association of Salaried Medical Specialists wrote two letters of complaint to the DHB about the culture of the department.
The letters warned of a "deteriorating management culture" in mental health services as experienced by a number of staff, although specific to two staff who had lodged complaints.
Ian Powell, director of the ASMS, told the Bay of Plenty Times the problems with the culture were among the "most extremely serious" he had experienced in his 30 years at the medical union.
"Some of our members had a very difficult time, they were emotionally harmed by the culture."
More than 140 staff in Tauranga and Whakatane were interviewed by O'Connell over 300 hours in a 12-week period between October and December 2017.
He found "a number of consistent themes and issues emerged".
"Micromanagement, inconsistency, playing favourites, bullying, and 'splitting' are the words most commonly used to describe the leadership and management practices."
Splitting was described as an approach that pits one person or team against another.
"The level of distress expressed by many staff was disturbing," O'Connell wrote.
He concluded there was "an embedded culture of fear" within the department, with an environment "of very low trust and a high degree of fear about speaking out" and it was "fertile ground for the ongoing cultivation of unacceptable and damaging behaviours".
"In an environment like this the level of clinical risk to clients is significant, because behaviours and fear of the consequences of raising issues are an impediment to maintaining safe and effective clinical care."
Staff felt "undervalued, unfairly treated, bullied and harassed" and this should not be overlooked or underestimated, wrote O'Connell.
"It is my considered view that people need to reflect and seriously ask themselves if their own past conduct was appropriate and reasonable or undignified harmful interaction, or behaviour that crossed the line..."
Two months before O'Connell started his investigation, the Times published leaked emails and a letter raising concerns about staff being attacked by patients, including by some high on drugs.
Staff had raised health and safety concerns internally and via the unions, with messaging about "management not listening". There were also a number of "complex and multifaceted" HR cases.
The values statement of the DHB is an acronym CARE which stands for: Compassion, All-one-team, Responsive, Excellence.
O'Connell said a number of dispirited staff had their own version: Contempt And Rejection Everyday.
He said the most common problems cited by staff in the confidential interviews were significant management/leadership issues, a power imbalance and a culture of fear.
The culture was so pervasive and unhealthy, O'Connell referred to "a range of deleterious outcomes that were avoidable and at times reprehensible".
He also provided direct quotes from staff.
One said: "I am very worried about clinical risk - the emphasis is so skewed towards quantity that we are at risk of severely dropping the standards on quality."
Pete Chandler, the DHB's chief operating officer, said the leadership restructure in mental health services in the middle of 2018 had seen a "very positive shift forward".
He said the initial focus was on the inpatient mental health service, and included looking at leadership, resources and culture. The focus then moved to the crisis team, where additional resourcing was approved.
"Culture change is not an easy process and takes considerable time, expertise and resilience," said Chandler, "however, we have taken the staff feedback as a gift and are systematically working through the areas of opportunity that were raised."
Most recently, Chandler said the MICAMHS (Maternal Infant Child and Adolescent Mental Health Services) team was identified as the next area within the department that needed "intensive support".
Last month, the outgoing service manager of that team wrote a scathing internal letter outlining what she said was a "toxic" work environment, which was sent to DHB management, and was also leaked to the Bay of Plenty Times.
Chandler said the DHB was working with its union partners and the staff "through historical issues, as well as growth challenges and evolving the team culture".
"We don't shy away from the hard stuff at BOPDHB and although it takes time, and we do have to prioritise our focus, we are totally committed to supporting culture change if this is required."
Health Minister David Clark said the Ministry of Health had been working with the Bay of Plenty DHB to improve the workplace culture, staff safety and wellbeing at its mental health services.
"The DHB has the financial resources to do this," said Clark, pointing out an annual boost of $103m for mental health services across all district health boards.
"I'm confident BOPDHB's new board led by Sir Michael Cullen will make sure the DHB delivers on its commitment to improve these services for patients and staff alike."
Ian Powell said the O'Connell report went "to the crux of recognising our concerns". While it would take time for the culture to turn around completely, he believed the DHB had taken positive steps to fix things.
"There will be ups and downs but it's on an upward trajectory."